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   Table of Contents    
ORIGINAL ARTICLE
Year : 2019  |  Volume : 23  |  Issue : 1  |  Page : 12-20  

A comparative evaluation of the micronutrient profile in the serum of diabetes mellitus Type II patients and healthy individuals with periodontitis


1 Department of Periodontics, A B Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, A B Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore, Karnataka, India
3 Department of Biochemistry, K S Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India
4 Department of Biochemistry, Central Research Laboratory, Nitte University, Mangalore, Karnataka, India

Date of Submission14-Jun-2018
Date of Acceptance28-Aug-2018
Date of Web Publication3-Jan-2019

Correspondence Address:
Dr. Biju Thomas
Department of Periodontics, A B Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_398_18

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   Abstract 


Background: Micronutrients play an important part in metabolism and maintenance of tissue function the maintenance of the integrity and vitality of the periodontal tissues depends on the availability of adequate nutrients, and it is possible that deficiencies can produce pathological alterations in the periodontal tissues. However, the association between nutritional factors and periodontal health is not fully understood. The essential micronutrients for maintaining health include zinc, copper, selenium, and iron. These micronutrients are required for a variety of biomolecules to maintain the normal structure, function, and proliferation of cells and also immune functions. Periodontal disease and diabetes mellitus (DM) are considered to have a bidirectional relationship, and periodontitis is recognized as the 6th major complication of DM. The number of studies on the role of micronutrients with regard to periodontal disease is limited. Aims: This study aims to evaluate the role of micronutrients-zinc, copper, selenium, and iron, in the serum of chronic periodontitis patients and chronic periodontitis with DM Type II patients, to see whether they can serve as potential markers for chronic periodontitis and also to assess whether periodontitis can have systemic effects. Materials and Methods: A volume of 5 ml of venous blood was collected from each of the study participants, from the antecubital vein. The blood was then centrifuged and stored at −20°C before being analyzed. Zinc, copper, and selenium were estimated by the atomic absorption spectrophotometry, bathophenanthroline method was used to estimate iron. Statistical Analysis: It was carried out using Student's t-test and analysis of variance. The honestly significant difference Tukey test and Pearson's correlation was also used. Results: The mean serum zinc levels were significantly higher in healthy controls as compared to Periodontitis and Periodontitis with DM type II. The mean serum copper levels were significantly higher in Periodontitis with diabetes as compared to controls and periodontitis. Serum selenium levels were significantly higher in controls as compared to periodontitis with diabetes. The mean serum iron levels were significantly higher in periodontitis with diabetes. The Zinc: Copper (Zn: Cu) ratio was found to be significant for the periodontitis with diabetes group. Conclusion: The results obtained from this study suggests that the serum levels of micronutrients Zn and Se were decreased and levels of Cu and Fe are increased in chronic periodontitis as compared to healthy control. There was a potentiated difference in the values in patients with DM Type II. The results show that the levels of these micronutrients can be used as effective biomarkers for chronic periodontitis and that periodontitis has systemic manifestations.

Keywords: Chronic generalized periodontitis, copper, diabetes mellitus type-II, micronutrients-zinc, selenium and iron


How to cite this article:
Thomas B, Prasad BR, Kumari NS, Radhakrishna V, Ramesh A. A comparative evaluation of the micronutrient profile in the serum of diabetes mellitus Type II patients and healthy individuals with periodontitis. J Indian Soc Periodontol 2019;23:12-20

How to cite this URL:
Thomas B, Prasad BR, Kumari NS, Radhakrishna V, Ramesh A. A comparative evaluation of the micronutrient profile in the serum of diabetes mellitus Type II patients and healthy individuals with periodontitis. J Indian Soc Periodontol [serial online] 2019 [cited 2019 Jun 16];23:12-20. Available from: http://www.jisponline.com/text.asp?2019/23/1/12/245326




   Introduction Top


Periodontal disease is an immunoinflammatory lesion occurring as a result of an interaction of the microbial plaque biofilm with the immune inflammatory response of the host and the subsequent alterations in the homeostasis of the bone and connective tissues.[1] Conventionally, it was accepted that periodontitis is an oral disease and the destruction of the tissues remains localized within the periodontium; however, current evidence suggests that periodontitis can produce alterations in systemic health.

Periodontitis has been recognized today as the 6th complication of diabetes mellitus (DM). Both the chronic disease conditions are said to have a bidirectional relationship. The two diseases have the capacity to induce an inflammatory response leading to the production of various mediators of inflammation. There is sufficient evidence currently available to suggest that DM type II is associated with an increased prevalence, extent, and severity of periodontal disease.[2]

Nutrition has a role in the maintenance of the periodontium. Studies have documented that deficiencies of several essential macro and micronutrients can be detrimental for the prognosis of periodontal diseases. Micronutrients such as zinc, copper, iron, and selenium play an important role in antioxidant defense, immune regulation, and neutralization of the inflammatory process.[3]

Studies have also shown that the homeostasis of micronutrients can be disrupted by DM, and the resultant imbalance of these micronutrients may play a role in altering the normal glucose and insulin metabolism.[4] However, the exact mechanisms by which nutritional deficiencies can contribute to periodontal destruction, or whether micronutrient homeostasis can be disrupted by periodontitis has not been understood.

Hence, there is a need to understand the role of micronutrients in the initiation and progression of periodontal disease and also to see whether they can serve as markers of periodontal disease.

Thus, the present study was conducted to evaluate the levels of micronutrients (Zinc [Zn], Copper [Cu], Iron [Fe], Selenium [Se]) in chronic periodontitis patients and chronic periodontitis with DM type II patients to better understand their association with periodontal disease.


   Materials and Methods Top


A cross-sectional study was conducted involving 300 individuals in the age group of 30–60 years from October 2010 to May 2015.

The sample size was calculated based on the assessment of various studies conducted earlier and the expected mean differences. The power of the study was fixed at 80%, and error was fixed at 5%. For Power 80%, Alpha level 5% and effect size 0.181 total sample size calculated for 3 groups is 300 that is 100 in each group.

The ethical clearance was obtained from the Central ethics committee, before the start of the study. All the participants enrolled into the study were given a consent form, which was explained to them and written consent was obtained. A case history was recorded for each subject enrolled in the study as per the case history format.

The body mass index (BMI) of all the 300 participants were also assessed according to the criteria by Garcia et al.[5] and participants who had a BMI above 25, i.e., overweight and obese individuals were excluded from the study.

Only participants who were free of any systemic diseases were included in Group I and III, and participants who were free of any systemic diseases other than DM type II were included in Group II. The participants in Group II were those who were under treatment for DM Type II and on oral diabetic drugs (Metformin derivatives) and dietary modifications for more than 1 and <5 years.

Participants included in Group I and II had chronic generalized severe periodontitis, as per the American Academy of Periodontology/Centre for Disease Control and Prevention classification of periodontal disease given by Eke et al.[6] The diagnosis of chronic generalized severe periodontitis was established based on the clinical findings of gingival inflammation and clinical attachment loss more than 5 mm, pocket depth more than 4 mm at 3 or 4 sites in more than four teeth in each quadrant with radiographic evidence of bone loss. Periodontal health was established as the absence of clinical signs of gingival inflammation and no evidence of bone loss in participants with good oral hygiene. All participants underwent periodontal examination by a single trained examiner. Aggressive periodontitis patients were excluded from the study.

Participants with a history of intake of antibiotics in the previous 4 weeks and also a history of intake of vitamin and mineral supplements and any periodontal treatment during the last 6 months were excluded from the study. Participants with a history of any form of tobacco usage and alcoholism, pregnant, and lactating women were also excluded from the study.

The random blood sugar and glycosylated hemoglobin assay were estimated and participants with a Random blood sugar (RBS) score of <120 and hemoglobin A1C score of <7 were included in the study. The periodontal status was also assessed before allotting the participants to the various groups. A single trained investigator screened and allotted the patients to all the three groups.

This being a cross-sectional study no nonsurgical treatment was carried out and no oral hygiene instructions given before data collection.

Study groups

  1. Group I consisted of 100 participants with moderate-to-severe chronic periodontitis
  2. Group II consisted of 100 participants with moderate to severe chronic periodontitis and also having DM type II
  3. Group III consisted of 100 participants who were systemically healthy and not suffering from any periodontal disease.


A detailed case history was recorded of each subject. Then, a periodontal examination was carried out, and the status of the periodontal condition was determined, the patient was also referred to a physician to determine the systemic condition.

Following this, the patients were allotted to the various groups as per the inclusion criteria. Patients who did not meet the various criteria were excluded from the study.

A volume of 2 ml of venous blood was collected from the antecubital vein from each of the study participants. The blood from each of the participants was centrifuged and stored at −20°C before being analyzed. The serum samples were then analyzed for the micronutrients using the GBC AVANTA atom absorption spectrophotometer.

Statistical analysis

Statistical analysis of the data was done using SPSS version 17 software (SPSS Inc, Chicago, IL, USA). The comparison of the means of the two groups was done using the Student's t-test. Analysis of variance (ANOVA) two-tailed test was used when the means of more than three groups were to be compared. Honestly significant difference Tukey test was used in conjunction with ANOVA to find means that were significantly different from each other. Pearsons correlation was used to find the correlation between variables measured under quantitative data. The “P” value (level of significance) <0.05 was considered to be statistically significant.

Biochemical study

A volume of 2 ml venous blood was collected from each subject from antecubital vein in plain tubes. The plain tubes were used to assess micronutrients. It was centrifuged and the serum obtained was stored at −20°C for subsequent analysis.

The micronutrients (copper, zinc, and selenium) were assessed by atomic absorption spectrophotometry. Atomic absorption spectroscopy is a technique which uses electron transition of a particular element to assess the concentration of a particular metal element or an analyte in a sample. Iron was assessed by spectrophotometer.


   Results Top


A cross-sectional study was conducted taking a total of 300 participants in the age range of 30–60 years reporting to the Department of Periodontics, A B Shetty Memorial Institute of Dental Sciences, Mangalore.

Serum micronutrient status

[Table 1] and [Graph 1] show the micronutrient levels in the three study groups and [Table 2] shows the multiple comparison of the micronutrient status between the groups.
Table 1: Comparison of micronutrient levels among the three groups using one-way analysis of variance

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Table 2: Post hoc tests (multiple comparisons of the micronutrient status between groups)

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When the mean serum zinc levels were compared between the groups, it was found to be statistically significant between all the three groups (P< 0.001).

The serum zinc levels were seen to be highest in Groups III (healthy control) 83.49 ± 16.66, lesser in Group I (periodontitis) 70.81 ± 10.40 and least in Group II (periodontitis with diabetes) 50.21 ± 7.90.

The mean serum copper levels when compared between the groups were found to be statistically significant between Group I and Group II and Group II and Group III (P< 0.001). There was no statistically significant difference between group I and III (P= 0.262).

The mean serum copper levels were seen to be highest in Group II (periodontitis with diabetes) 112.01 ± 15.89, lesser in Group III (healthy control) 88.85 ± 13.61, and least in Group I (periodontitis) (86.09 ± 12.38).

The mean serum selenium levels were compared between the groups and were found to be statistically significant between group I and II, and II and III. (P < 0.001). The comparison between group I and III showed that there was no statistically significant difference (P = 0.031).

The mean serum selenium levels were found to be highest in Group III (healthy control) 140.30 ± 26.07, lesser in Group I (periodontitis) 131.39 ± 24.76 and least in Group II (Periodontitis with diabetes) 98.41 ± 23.42.

The mean serum iron level when compared between the groups was found to be statistically significant between Group I and II and Group II and III (P< 0.001). There was no statistically significant difference between group I and III (P= 0.870).

The mean serum iron levels were found to be highest in Group II (periodontitis with diabetes) 158.12 ± 18.39, lesser in Group I (periodontitis) 126.93 ± 20.58, and least in Group III (healthy control) 391 ± 25.68.

The Zn: Cu ratio between the groups was also correlated.[Table 2]. The correlation was not found to be significant for Group I, periodontitis group (P = 0.811). However, the correlation was found to be significant for Group II, periodontitis with diabetes group (P = 0.006) and not significant for Group III healthy control (P = 0.259).

[Table 3] shows the correlations in Group I, [Table 4] of Group II, and [Table 5] of Group III. [Graph 2] shows the correlation of the Zn:Cu ratio in the three study groups.
Table 3: Correlations between Zinc and Copper - Group I

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Table 4: Correlations between Zinc and Copper- Group II

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Table 5: Correlations between zinc and copper - Group III

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   Discussion Top


Periodontal disease is the second most common oral disease that is initiated by specific species of pathogenic microorganisms in the dental biofilm. If not treated, it results in apical migration of the junctional epithelium, and destruction of the periodontal attachment apparatus including the alveolar bone.

This local disruption of the homeostatic balance within the periodontal tissues may not be confined to the periodontium alone. Currently, research shows that the cells of the immune system can transmit inflammatory responses to other parts of the body when challenged by local periodontal stimuli.[7]

The two possible mechanisms suggested by which this can occur are by direct migration and colonization of the pathogenic microorganisms to distant organs, leading to an inflammatory reaction at sites distant from the point of infection, and also the systemic inflammation as a result of metastatic periodontal inflammation.

Hence, in this study to assess the micronutrient in chronic periodontitis patients, the serum of patients was chosen as compared to saliva or gingival crevicular fluid to better understand the hypothesis that chronic periodontal inflammation can be a contributing risk factor for systemic inflammation at distant sites.

However, the studies that have demonstrated the association between periodontitis and various systemic diseases have been mostly retrospective studies. They can help to identify a possible association, but retrospective studies cannot demonstrate causation. Hence, the evidence available currently is insufficient to establish the association between periodontitis and various systemic diseases.

Among all the systemic disease studied, for their association with periodontitis, most evidence is available for the possible association between DM and periodontal diseases.

Studies on patients with diabetes and periodontal disease have revealed that both diseases have a synergistic effect when they coexist in an individual. However, the exact mechanisms by which hyperglycemia can lead to increased periodontal tissue destruction is not yet fully understood. It is hypothesized that long-term hyperglycemia, seen in diabetic patients, can lead to increased anaerobic infections in the periodontal tissues with a hyperactive immune response, which can cause chronic inflammation in various organ systems of the body including the periodontium.[8]

Hence, in this study, chronic periodontitis patients with DM Type II, have been included as a separate group, to see the extent of the potentiated effect of the two diseases existing together on the micronutrient status.

Dental diseases including periodontal diseases have a considerable influence on the self-esteem and quality of life of an individual.[9] Nutrients play a regulatory role in preserving the health of the human body. Micronutrients and antioxidants play an essential role in coping with the oxidative stress and also for the adequate immune response. Alterations in the nutritional status can alter the tissue homeostasis, reduce the resistance to infection, and reduce tissue repair capacity. There is a continuous synergy between the nutrition and the integrity of the oral cavity in oral health and disease.[10]

In this study, the trace elements zinc, copper, selenium, and iron are analyzed because they are essential components of the various antioxidant enzyme systems. These micronutrients play an important role in the various regenerative processes occurring in the body, for combating the effects of oxidative stress and also to maintain an adequate immune response. The deficiency, imbalance, or excess of these micronutrients can cause various diseases. Due to their influence on the functioning of the immune system the micronutrients zinc, copper, selenium, and iron play an important role in the host microbial interaction.

Till date, very few studies have analyzed the alterations in serum micronutrients and the interrelationship between the two in chronic periodontitis. This study looks at the possibility of a potential link between the micronutrients in chronic periodontitis patients.

In the present study, it was observed that the majority at the patients belonged to the age group of 42–49 years for the study Groups I and II. This is due to the fact that both chronic periodontitis and DM Type II are both diseases with an onset in the middle age group. The sex-wise distribution showed that most of the participants in the study groups are male. This is consistent with the fact that the prevalence of both chronic periodontitis and DM Type II is more in males.

The DM Type II cases selected for this study had a minimum duration of 1 year and a maximum duration of 5 years with a mean average of 3.33 years. Patients with a longer duration of diabetes were excluded from the study, to eliminate the possibility of other systemic complications occurring along with DM.

In our study, the mean serum zinc levels were seen to be highest in the control group, significantly decreased in the periodontitis group and least in the DM Type II group. There was a statistically significant difference between the three groups.

This is in accordance with the study conducted by Gulkazi et al. which showed that the mean values of zinc were significantly reduced in diabetic participants as compared to nondiabetics.[11]

The results are also in accordance with the studies conducted by various authors who have reported lower level of zinc in periodontitis patients as compared to controls.[12],[13],[14]

Zinc is an a intracellular signaling molecule required for the synthesis of various proteins and also for cellular proliferation. Zinc deficiency leads to reduced osteoblastic activity, decreased synthesis of collagen as well as a subdued alkaline phosphatase activity. Adequate intake of zinc helps to maintain the integrity of skin and mucous membranes.[15]

Zinc also functions in several AO enzyme systems. Zinc deficiency, indirectly indicates a reduced level of immune status of the body, and is an additional factor responsible for increased rate of calculus formation in periodontal disease. Tissue levels of zinc can theoretically modify the defense mechanisms of the periodontium. Normal value of zinc in healthy individuals is 60–130 g/dl.

Studies have also reported that zinc deficiency in gingiva causes an increase in the permeability of the gingival epithelium for bacteria and an inverse correlation between the zinc levels and alveolar bone loss.[16],[17]

Studies have also stated that decrease in serum zinc levels can lead to decreased phagocytosis by macrophages and neutrophils, decreased NK cell activity, and decreased generation of oxidative burst; It can also cause the altered structure of α2 macroglobulin and increased interaction with cytokines and proteases, thus influencing the immune function indirectly.[18]

Tapiero and Tew have also reported that zinc has indirect effects by stabilizing the structure of the cell membrane, the structural integrity of SOD and maintaining the metallothionein tissue concentrations. Zinc deficiency for extended periods of time can render an organism more susceptible to injury induced by oxidative stresses.[19]

Thus, it can be suggested that zinc deficiency can lead to suppressed immunity and increased oxidative stress. This can cause poor regenerative capacity is an individual which can predispose to chronic periodontitis.

The mean serum copper levels in the study were seen to be highest in Group II (Periodontitis with diabetes), lesser in Group III (healthy control) and least in Group I (periodontitis). The results were statistically significant between Group I and II and I and III and not significant between Group I and III.

Copper is important in the production of hemoglobin, myelin, collagen, and melanin. Copper is also essential for several proteins and enzymes that participate in Iron and lipid metabolism, connective tissue synthesis, and functions of the immune and central nervous systems. Copper levels are seen to be elevated in various disease conditions which suggest a requirement of this micronutrient for the synthesis of copper-dependent regulatory proteins and enzymes in the body, required to combat the disease. Normal value of copper in healthy individuals is 70 – 150 g/dl.

Copper plays a role in several AO enzyme systems especially as a part of the SOD family of AO, which helps to quench superoxide free radicals. Copper ions play a role in the conversion of superoxide to hydrogen peroxide and hydroxyl radicals. Thus, higher levels of copper can lead to increased oxidative stress which can cause increased periodontal tissues destruction.[20],[21] Freeland et al. have stated that elevated serum copper levels alter collagen metabolism increasing the susceptibility of the individual for chronic periodontitis.[22]

In animal studies, excess copper levels in serum have been associated with impaired immunity. This is due to its effects on the complement network, the depressed neutrophil numbers, lymphocyte proliferation, and antigen-specific antibody production.[20],[23]

Serum copper levels are seen to be elevated during inflammation. This is said to be due to an endogenous leukocyte mediator at the site of inflammation that acts as a feedback signal to mobilize copper from the liver. This mechanism can explain elevated serum copper levels found in chronic periodontitis and DM Type II patients. Lysyl oxidase, a specific monoamine oxidase, is a copper metalloenzyme which is involved in stabilizing collagen. Elevated levels of copper in the serum during chronic inflammation could be due to the accumulation of one or more of these enzymes in the serum.[22]

This study points to a possible link between elevated copper levels and chronic periodontitis with DM type II. However, the fact that the comparison of copper levels between the periodontitis group and control group was nonsignificant points to the fact that the elevated copper levels in Group II (DM with periodontitis) is due to the effects of DM Type II and copper levels are not seemingly associated with chronic periodontitis.

Zinc-copper ratio

The results of this study show that the levels of zinc and copper in chronic periodontitis are inversely related. Studies on other inflammatory conditions such as inflammatory bowel disease have shown that there is an inverse relationship between zinc and copper levels.[24]

This may be due to the fact that the synthesis of the protein metallothionein is stimulated by zinc. This protein binds to copper thereby decreasing its absorption. The increased concentration of copper seen associated with various inflammatory disease conditions can cause decreased absorption of zinc in the small intestine.

Although there are no studies which have considered the Zn: Cu ratio in periodontal diseases, this ratio has been considered as a reliable marker for malignancies. Studies by Ayinampudi and Narsimhan et al. showed that there is an increase in the Zn: Cu ratio in oral leukoplakia, oral submucous fibrosis and oral squamous cell carcinoma as compared to controls.[25] It is possible that the Zn: Cu ratio can be considered as a possible marker for the progression of chronic periodontitis lesions; however, further studies need to be conducted in this regard, assessing the Zn: Cu ratio according to the severity of the disease.

[Graph 3] of the scattered diagram shows the correlation between two variables. Looking at the scatter of the points, the degree of correlation is seen. The lesser the points are scattered the higher is the degree of correlation. In the scatter diagram of the Zn: Cu ratio in group, i.e., the points plotted are closer to each other and are less scattered. This indicates a high level of correlation.



The mean serum selenium levels were seen to be highest in Group III (control), lesser in Group I (periodontitis), and least in Group II (periodontitis with DM). The results were statistically significant between Group I and II and Group II and III and nonsignificant between Group I and III.

Selenium is an essential micronutrient in the body that functions as a cofactor for the reduction of antioxidant enzymes such as glutathione peroxidases. It functions as an AO in concert with Vitamin E to protect the body from oxidative damage. Normal value of selenium in healthy individuals is: 0.67-2 M/L.

It also influences both the acquired and innate immune systems. Selenium also has an important role in redox regulation and antioxidant function through the glutathione peroxidase enzyme systems. Thus, selenium protects the host from oxidative stress generated during the inflammatory reactions.[26] Hence, levels of selenium are expected to be inversely related to various inflammatory diseases.

Studies have reported low serum levels of selenium in association with chronic periodontitis.[27],[28],[29] In this study, although serum selenium levels were lower in chronic periodontitis compared to the control group, it was not statistically significant.

However, the selenium levels in Group II (chronic periodontitis with DM type II) were significantly lesser compared to the chronic periodontitis and control group.

Studies by Kornhauser et al.[30] and Akinloye et al.[31] have reported significantly lower serum selenium levels in DM. Type II patients. This is in accordance with the results obtained in this study. However, a study by Bleys et al. to assess selenium and diabetes in US adults reported that high serum selenium levels were positively associated with the prevalence of diabetes.[32]

Studies by Erbayraktar et al.[29] and Hwang et al.[33] on the effects of selenium supplementation in experimental DM have shown that selenium augmented the AO defense by increasing glutathione peroxidase activity.

Results of this study highlight the role of selenium in DM Type II patients with chronic periodontitis and not in systemically healthy individuals with chronic periodontitis. Thus, selenium levels do not seem to be associated with chronic periodontitis as per this study.

The mean serum Iron levels were seen to be highest in Group II (periodontitis with DM), less in Group I, and least in Group III (control). The values were statistically significant between Group I and II and II and III, but not significant between Group I and III.

Iron is one of the most important micronutrients involved in nutrition. It is a functional component of immunoglobulin and also helps to maintain immune functions. Iron is required for the hydroxylation of proline and lysine, and hence, severe iron deficiency can result in impaired collagen production. In the presence of Fe2+ ions, hydrogen peroxide undergoes Fenton reactions forming the most potent of all oxygen radicals, the hydroxyl radical (OH). Normal value of Iron in healthy individuals is 65–198 g/dl.

Iron in the body serves as a carrier of oxygen to the tissue from the lungs by the hemoglobin of the red blood cells and also as a transport medium for electrons within cells. It is also an integral part of the various enzyme systems. Iron deficiency can affect the development of the teeth and periodontium, but studies on human population are not available.[34]

Excess serum concentration of iron has been implicated in the pathogenesis of diabetes and its complications.[35],[36],[37]

A study by Thomas et al., Madsaact R J et al. reported that elevated iron indices are more common in patient with diabetes, and free iron serves as a catalyst for lipid and protein oxidation and the formation of ROS.[38] It is possible that this points to the role of iron in the development of insulin resistance and diabetes.[28] Thus, patients with elevated iron levels may have an early age of onset of diabetes than patient with normal or low iron indices.

Studies on the periodontal status of patients with iron deficiencies are limited. Mukherjee[39] reported that iron might be an important factor in periodontal disease activity since it can enhance the growth and virulence of microorganisms in the subgingival plaque. Nutrients are required for the growth and virulence of micro organisms to overcome the host defenses of the nutrients required; iron stands as an essential element because of its necessity various stages of cell metabolism. A large number of in vitro and in vivo studies have shown that the addition of Iron enhances the growth of various strains of microorganisms in the host cells, tissues and fluids. Large numbers of studies on experimental infection have shown that Iron enhances bacterial virulence of several strains of bacteria.

Results of this study show that gingival crevicular fluid (GCF) concentration of Iron was 3 fold higher in ligature-induced periodontitis sites in beagle dogs compared to pre ligation sites, therefore, based on the available literature, it is suggested that the increase concentration of iron in GCF in periodontitis sites migt play an important role in the enhancement of growth and virulence of the microorganisms of the subgingival plaque.

Studies have shown that the concentration of iron in the gingival crevicular fluid was increased in diseased sites; however, it is not a good indicator for assessing changes in disease severity, resulting from periodontal treatment.[40] Mallek studied the correlation of iron levels with gingival sulcular epithelial permeability but found no significant correlation.[41]

Copper, selenium, and iron levels were not statistically significant when comparing the chronic periodontitis group to healthy controls. Hence, there is no implication of the results of this study for the above three micronutrients with regard to chronic periodontitis. However, considering the role of zinc in maintaining tissue integrity, zinc supplementation may be indicated in zinc-deficient individuals.


   Conclusion Top


The conclusions that can be drawn from the present study are as follows:

  1. The serum levels of zinc are significantly reduced in chronic periodontitis patients as compared to healthy controls
  2. The serum levels of copper, selenium, and iron were not significantly different between chronic periodontitis and healthy controls
  3. The serum levels of zinc, copper, selenium, and iron were significantly altered between chronic periodontitis and chronic periodontitis with DM Type II patients
  4. The present study supports and extends the view that the assessment of the micronutrient can serve as possible biomarkers for chronic periodontitis and that periodontitis has systemic manifestations
  5. This being a cross-sectional study confounding factors could affect the outcome. However, efforts have been made to minimize the confounding factors like obesity in this study.


Scope for further work

In this study having assessed the role of micronutrients in the serum of chronic periodontitis patients and chronic periodontitis with DM Type II, the future thrust area could be to study the serum levels of micronutrients and AO in other inflammatory systemic diseases like atherosclerosis, pre term low birth weight conditions and chronic obstructive pulmonary disease, to better understand the association between periodontal disease and the various chronic inflammatory systemic diseases and conditions.

A comparative study where the micronutrient levels in serum, saliva, gingival crevicular fluid and gingival tissue samples are compared, could also be carried out, to better understand both the local and systemic nature of chronic periodontitis lesions, There are no published studies available where the analysis of micronutrients have been carried out in all the four samples in the same patient.

With advances in the field of immunohistochemistry in future, it should be possible for more precise detection of micronutrients with better analytical methods.

In our study, the GBC AVANTA atom absorption spectrophotometer was used.

The technique of atomic absorption spectrometry was based on the Beer-Lambert law.

Iron was assessed by the bathophenanthroline method.

Future work should also be directed towards developing cost-effective evaluation kits which would be very useful in regular monitoring of chronic periodontitis patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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